WHIPLASH CARE GUIDELINES
 
   

Whiplash Care Guidelines

This section was compiled by Frank M. Painter, D.C.
Send all comments or additions to:
  Frankp@chiro.org


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I would like to thank Arthur C. Croft, DC, MS, MPH, FACO, FACFE, FAAIM for the generous contribution of these 6 tables from the 12th chapter of his text Whiplash Injuries: The Cervical Acceleration/ Deceleration Syndrome.   To the best of my knowledge, this is the only on-line source of well documented treatment guidelines for the whiplash patient, which actually suggests the number of treatments which may be necessary.   Please refer to Dr. Croft's text (3rd edition, 2001) for further explanation.   You might also enjoy some of   Dr. Croft's articles and his November 15, 2000 article, referring to these guidelines, titled Guidelines for the Management of CAD Trauma.


Table 12.1

Effects of Experimental Spinal Fixation 1

  1. Fibrous ingrowth
  2. Vascular invasion of tidemark
  3. Osteophytosis
  4. Subchondral remodeling
  5. Chondrolysis and cloning
  6. Absence of proteoglycans
  7. Fibrillated cartilage
  8. Loss of motion

1 Adapted from:   Kahanovitz N, Arnoczky SP, Levine DB, Otis JP:   "The effects of internal fixation on the articular cartilage of unfused canine facet joint cartilage."
Spine 9(3):   268-272, 1984

 
   

Table 12.2

Common Factors Potentially Complicating
CAD Trauma Management 1
  1. Advanced age
  2. Metabolic disorders
  3. Congenital anomalies of the spine
  4. Developmental anomalies of the spine
  5. Degenerative disc disease
  6. Disc protrusion (HNP)
  7. Spondylosis
  8. Facet arthrosis
  9. Rheumatoid arthritis or other arthritides affecting the spine
  10. Ankylosing spondylitis or other spondylarthropathy
  11. Scoliosis
  12. Prior cervical spinal surgery 2
  13. Prior lumbar spinal surgery 2
  14. Prior vertebral fracture
  15. Osteoporosis
  16. Paget's disease or other disease of bone
  17. Spinal stenosis or foraminal stenosis
  18. Paraplegia or quadriplegia
  19. Prior spinal injury

1 From Croft AC:   Treatment paradigm for cervical acceleration/deceleration injuries (whiplash).   Am Chiro Assoc J Chiro 30(1):   41-45, 1993.

2 Especially laminectomy and discectomy.

 
   

Table 12.3

Guidelines for Frequency and Duration of Care in
Cervical Acceleration/Deceleration Trauma 1
 

Daily

3x/wk

2x/wk

1x/wk

1x/mo

TD 2

TN 2

Grade I

1 wk

1-2 wk

2-3 wk

<4 wk

....3

<11 wk

<21

Grade II

1 wk

<4 wk

<4 wk

<4 wk

<4 mo

<29 wk

<33

Grade III

1-2 wk

<10 wk

<10 wk

<10 wk

<6 mo

<56 wk

<76

Grade IV

2-3 wk

<16 wk

<12 wk

<20 wk

....4

....4

....4

Grade V

Surgical stabilization necessary--chiropractic care is post-surgical

1 Adapted from Croft AC:   Treatment paradigm for cervical acceleration/deceleration injuries (whiplash).   Am Chiro Assoc J Chiro 30(1):   41-45, 1993.

2 TD indicates treatment duration; TN treatment total number;

3 Possible follow-up at 1 month.

4 May require permanent monthly or p.r.n. treatment.

 
   

Table 8.12 is from Chapter 8 and explains the Grade I-V classification system used in the Table 12.3 above.

Table 8.12

Classification of Cervical Acceleration/Deceleration
Injuries from Motor Vehicle Accidents (SRISD)
1

A. Types of Collisions 2

Type I

Primary rear impact (struck car moving or stationary)

Type II

Primary side impact

Type III

Primary frontal impact

 

B. Grades of Severity of Injury

Grade I

Minimal;   No limitation of motion;   No ligamentous injury;   No neurological findings

Grade II

Slight;   Limitation of motion;   No ligamentous injury;   No neurological findings

Grade III

Moderate;   Limitation of motion;   Some ligamenetous injury;   Neurological findings may be present

Grade IV

Moderate to Severe;   Limitation of motion;   Ligamentous instability;   Neurological findings present;   Fracture or disc derangement

Grade V

Severe;   Requires surgical management/stabilization

 

C. Stages of Injury

Stage I

Acute;   Inflammatory phase;   Up to 72 hours

Stage II

Subacute;   Repair phase;   72 hours to 14 weeks

Stage III

Remodeling phase;   14 weeks to 12 months or more

Stage IV

Chronic;   Permanent


1
Adapted from Croft, AC:   "A Proposed Classification of Cervical Acceleration/Deceleration Injuries with a Review of Prognostic Research"
Palmer J Research 1994;   1(1):   10-21

2 Occupant may be driver or passenger

SRISD = Spine Research Institute of San Diego. These criteria do not consider loss of consciousness, the use of seatbelts/shoulder harnesses, or other factors that will be accounted for in a forthcoming revised prognostic index.

 
   

Table 12.4

Treatment Adjuncts in Cervical Acceleration/Deceleration Trauma

Modality

Stage I

Stage II

Stage III

Stage IV

Cervical pillow

All grades

All grades

All grades

All grades

Cervical collars

 

  -   Rigid

Grades III-V 1,2

Grades III-V 1,2

--------

--------

  -   Soft

Grades II and III 1,2

--------

--------

--------

Home traction

--------

Grades II-IV 2

Grades II-IV

Grades II-IV

Home exercise

--------

Grades II-IV 2

Grades II-IV 2,3

--------

Ice

All grades

All grades

As needed

--------

Vit/min. suppl.

All grades

All grades

All grades

Recommended

DTM 4

Grades II-IV

Grades II-IV

As needed

--------

1 See text for indications.

2 Unless contraindicated.

3 Grade V after surgery.

4 Deep tissue massage.

 
   

Table 12.5

Contraindications to Manipulative Therapy

Relative Contraindications

Patients with (+) George's test
Patient with prior stroke
Females on oral contraceptives
Abdominal aortic aneurism
Vertebiobasilar syndrome
Metastatic disease
Disc herniation
Spondylarthropathy
Severe spondylosis
Moderate to severe osteoporosis
Metabolic bone disease
Osteomyelitis
Discitis
Stable spinal fracture
Severe atherosclerosis
Osteogenesis imperfecta
Clotting disorders
Intersegmental instability

Absolute Contraindications

Unstable spinal fracture
Acute spinal cord injury
Lack of formal training in spinal manipulation
 
   

Table 12.6

Heating Modalities: Modes of Transfer 1

Mode of Heat Transfer

Modality

Depth

Conduction

 

Convection


 

Conversion

Hot packs
Paraffin bath


Fluidotherapy
Hydrotherapy
Moist air


Radiant heat
Laser
Microwave
Short wave
Ultrasound

Superficial heat

 

 

 


Deep heat

1 Adapted from Lehman JF, de Lateur BJ:   "Therapeutic heat."
In:   Lehman JF, ed. Therapeutic Heat and Cold. 3rd ed. Baltimore: Williams & Wilkins, 1982:   404-562





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